1. A 4-year-old child is hospitalized with a suspected diagnosis of Wilms tumor.

The

nurse assists in developing aplan of care and suggests avoiding which of the following?
1. Palpating the abdomen for a mass
2. Checking the urine for the presence of hematuria
3. Monitoring the temperature for the presence of fever
4. Monitoring the blood pressure for the presence of hypertension
Answer: 1 Rationale: A Wilms tumor is a tumor of the kidney. If Wilms tumor is
suspected, the mass should not be palpated. Excessive manipulation can cause seeding of
the tumor and cause the spread of the cancerous cells. Fever, hematuria, and hypertension
are clinical manifestations associated with Wilms tumor.

2. A pregnant woman complains of being awakened frequently by leg cramps. The nurse
reinforces instructions to the clients partner and tells the partner to:
1. Dorsiflex the clients foot while flexing the knee.
2. Dorsiflex the clients foot while extending the knee.
3. Plantarflex the clients foot while flexing the knee.
4. Plantarflex the clients foot while extending the knee.
Answer: 2 Rationale: Leg cramps often occur when the pregnant woman stretches her leg
and plantarflexes her foot. Dorsiflexion of the foot while extending the knee stretches the
gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping.
3. A client being prepared for a cesarean delivery is brought to the delivery room. To
maintain optimal perfusion of oxygenated blood to the fetus, the nurse places the client in
a:
1. Trendelenburg position
2. Semi-Fowlers position
3. Supine position with a wedge under the right hip
4. Prone position
Answer: 3 Rationale: Vena cava and descending aorta compression by the pregnant uterus
impede blood return from the lower trunk and extremities, therefore decreasing cardiac
return, cardiac output, and blood flow to the uterus and subsequently to the fetus. The
best position to prevent this would be side-lying, with the uterus displaced off the
abdominal vessels. Positioning for abdominal surgery necessitates a supine position;
however, a wedge placed under the right hip provides displacement of the uterus. The
Trendelenburg position places pressure from the pregnant uterus on the diaphragm and

lungs, decreasing respiratory capacity and oxygenation. A semi-Fowlers or prone

position is not practical for this type of abdominal surgery.
4. A nurse is asked to assist the primary health care provider in performing Leopold
maneuvers on a client. Which nursing intervention should be implemented before this
procedure is performed?
1. Locate fetal heart tones
2. Have the client drink 8 ounces of water
3. Warm the sonogram gel
4. Have the client empty her bladder
Answer: 4 Rationale: An empty bladder contributes to a womans comfort during the
examination. Drinking water to fill the bladder and warming sonogram gel may be
performed prior to a sonogram (ultrasound). Often, Leopolds maneuvers are performed
to aid the examiner in locating the fetal heart tones.
5. A woman in active labor has contractions every 2 to 3 minutes lasting 45 seconds. The
fetal heart rate between contraction is 100 beats per minute. Based on these findings, the
priority nursing intervention is to:
1. Notify the registered nurse (RN) immediately.
2. Encourage relaxation and breathing techniques between
contractions.
3. Continue monitoring labor and fetal heart rate.
4. Monitor maternal vital signs.
Answer: 1
Rationale: Fetal bradycardia between contractions may indicate the need for immediate
medical management. The nurse would immediately contact the RN, who in turn would
contact the physician. Options 2, 3, and 4 will delay necessary and immediate
interventions.
6. A nurse is assigned to assist in caring for a client being admitted to the birthing center
in early labor. On admission, the nurse would initially:
1. Check pelvic adequacy.
2. Administer an analgesic.
3. Estimate fetal size.
4. Determine maternal and fetal vital signs.
Answer: 4Rationale: To evaluate a woman's physical well-being, the temperature, pulse,
respirations, and blood pressure, as well as the fetal heartbeat, are checked. Option 2 is

incorrect because it would be too premature for an analgesic. Medication given too early
tends to slow or stop labor contractions. Options 1 and 3 are incorrect. These assessments
should be done by the physician or a nurse midwife during prenatal visits.
7. Leopolds maneuvers will be performed on a pregnant client. The client asks the nurse
about this procedure. The nurse responds knowing that this procedure:
1. Determines the lie and attitude of the fetus
2. Is a systemic method for palpating the fetus through
the maternal back
3. Is a systemic method for palpating the fetus through
the maternal abdominal wall
4. Measures the height of the maternal fundus
Answer: 3 Rationale: Leopolds maneuvers comprise a systemic method for palpating the
fetus through the maternal abdominal wall. Options 1, 2, and 4 are incorrect.
8. After delivery, a nurse checks the height of the uterine fundus. The nurse expects that
the position of the fundus would most likely be noted:
1. At the level of the umbilicus
2. Above the level of the umbilicus
3. One fingerbreadth above the symphysis pubis
4. To the right of the abdomen
Answer: 1 Rationale: Immediately after delivery, the uterine fundus should be at the level
of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen. If
the fundus is above the umbilicus, this may indicate that there are blood clots in the
uterus that need to be expelled by fundal massage. If the fundus is noted to the right of
the abdomen, it may indicate a full bladder.
9. A nurse is caring for a postpartum client. Four hours postpartum, the clients
temperature is 102 F (38.9 C). The appropriate nursing action would be to:
1. Continue to monitor the temperature.
2. Notify the registered nurse, who will then contact the physician.
3. Apply cool packs to the abdomen.
4. Remove the blanket from the clients bed.
Answer: 2 Rationale: In the postpartum period, the mothers temperature may be elevated
during the first 24 hours as a result of dehydration. However, if the temperature is more
than 2 F above normal, this may indicate infection, and the physician will need to be
notified.

10. A nurse is assigned to care for a client in the immediate postpartum period who
received epidural anesthesia for delivery, and the nurse monitors the client for
complications. Which of the following would best indicate a hematoma?
1. Complaints of a tearing sensation
2. Complaints of lower abdominal discomfort
3. Changes in vital signs
4. Signs of heavy bruising
Answer: 3 Rationale: Changes in vital signs indicate hypovolemia in the anesthetized
postpartum woman with vulvar hematoma. Options 1 and 2 are inaccurate for a client
who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely
to indicate the presence of a hematoma.
11. A nurse is assisting in planning care for the postpartum woman who has small vulvar
hematomas. To assist in reducing the swelling, the nurse should:
1. Check the vital signs every 4 hours.
2. Prepare a heat pack for application to the area.
3. Measure the fundal height every 4 hours.
4. Prepare an ice pack for application to the area.
Answer: 4 Rationale: Application of ice will reduce swelling caused by hematoma
formation in the vulvar area. Options 1, 2, and 3 will not reduce the swelling.
12. A pregnant human immunodeficiency virus (HIV)positive woman delivers a baby.
The nurse provides guidance to help the client make decisions regarding newborn care.
The nurse determines that additional guidance is needed if the woman states that she will:
1. Be sure to wash her hands before and following bathroom use.
2. Be sure to wash her hands before feeding the newborn.
3. Breast-feed, especially for the first 6 weeks postpartum.
4. Administer the prescribed antiviral medication to the newborn for the first 6 weeks
after delivery.
Answer: 3 Rationale: The mode of perinatal transmission of HIV to the fetus or neonate
of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum
periods. HIV transmission can occur during breast-feeding; thus, HIV-positive clients are
encouraged to bottle feed their neonates. Antiviral medications will be prescribed for the
neonate for the first 6 weeks of life. The principles related to hand washing need to be
taught to the mother.

14. A pregnant woman has a positive history of genital herpes, but has not had lesions
during this pregnancy. The nurse plans to provide which of the following information to
the client?
1. You will be isolated from your newborn following delivery.
2. You will be evaluated at the time of delivery for herpetic genital tract lesions, if
present, a cesarean delivery will be needed.
3. There is little risk to your neonate during this pregnancy, birth, and following
delivery.
4. Vaginal deliveries can reduce neonatal infection risks, even if you have an active
lesion at birth.
Answer: 2 Rationale: If herpetic genital lesions are present at the time of delivery, a
cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the
absence of herpetic genital lesions, a vaginal delivery may be indicated unless there are
other reasons for performing a cesarean delivery. Maternal isolation is not necessary, but
potentially exposed neonates should be cultured on the day of delivery.
15. A nurse administers erythromycin ointment (0.5%) to the newborns eyes, and the
mother asks the nurse why this is done. The nurse tells the client that this is routinely
done to:
1. Minimize the spread of microorganisms to the neonate from invasive procedures
during labor.
2. Protect the neonate's eyes from possible infections acquired while hospitalized.
3. Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a
woman with an untreated gonococcal infection.
4. Prevent cataracts in the neonate born to a woman who is susceptible to rubella.
Answer: 3 Rationale: Erythromycin ophthalmic ointment (Ilotycin ophthalmic) 0.5% is
used as a prophylactic treatment of ophthalmia neonatorum, which is caused by the
bacteria Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law.
Options 1, 2, and 4 are not the purposes of administering this medication to the newborn
infant
16. A client asks the nurse why her newborn baby needs an injection of vitamin K. The
nurse makes which statement to the client?
1. Your newborn needs vitamin K to develop immunity.
2. The vitamin K will protect your newborn from becoming jaundiced.
3. Newborns are deficient in vitamin K. This injection prevents your baby from
abnormal bleeding.

4. Newborns have sterile bowels and the vitamin K will colonize the bowel with the
necessary bacteria.
Answer: 3 Rationale: Vitamin K is necessary for the body to synthesize coagulation
factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. It
promotes liver formation of the clotting factors II, VII, IX, and X. Newborn infants are
vitamin Kdeficient because the bowel does not have the bacteria necessary for
synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces
vitamin K. The newborn infants bowel does not support the normal production of
vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria
as food is ingested. Vitamin K does not promote the development of immunity or prevent
the infant from becoming jaundiced.
17. A nurse is assigned to assist in caring for a neonate born to a mother with acquired
immunodeficiency syndrome (AIDS). The nurse understands that which of the following
should be included in the plan of care?
1. Instruct breast-feeding mothers regarding treatment of their nipples with an antifungal
cream.
2. Monitor the neonates vital signs routinely.
3. Maintain standard precautions at all times while caring for the neonate.
4. Initiate referral to evaluate for blindness, deafness, learning, or behavioral problems in
the neonate.
Answer: 3 Rationale: The neonate born of a mother with AIDS must be cared for with
strict attention to universal precautions. This prevents the transmission of the infection
from the neonate, if infected, to others, and prevents the transmission of other infectious
agents to the possibly immunocompromised neonate. A mother with AIDS should not
breast-feed. Options 2 and 4 are not specifically associated with the care of a potentially
AIDS infected neonate.
18. A nurse in the newborn nursery receives a telephone call to prepare for the admission
of a 43-week-gestation newborn infant with Apgar scores of 1 and 4. In planning for
admission of this infant, the nurses highest priority should be to:
1. Connect the resuscitation bag to the oxygen outlet.
2. Turn on the apnea and cardiorespiratory monitor.
3. Set up the intravenous line with 5% dextrose in water.
4. Set up the radiant warmer control temperature at 36.5 C (97.6 degrees F).
Answer: 1 Rationale: The highest priority on admission to the nursery for a newborn with
low Apgar scores is airway support, which would involve preparing respiratory
resuscitation equipment. The remaining options are also important, although they are of
somewhat lower priority. The newborn infant will be placed on a cardiorespiratory
monitor. Setting up an IV with 5% dextrose in water would provide circulatory support.

The radiant warme will provide an external heat source, which is necessary to prevent
further respiratory distress.
19. A nurse is caring for a post-term neonate immediately after admission to the nursery.
The priority nursing action would be to monitor:
1. Urinary output
2. Total bilirubin levels
3. Blood glucose levels
4. Hemoglobin and hematocrit
Answer: 3 Rationale: The most common metabolic complication in the post-term
newborn is hypoglycemia, which can produce central nervous system abnormalities
and mental retardation if not corrected immediately. Urinary output, although
important, is not the highest priority action. Hemoglobin and hematocrit levels are
monitored because the post-term neonate exhibits polycythemia, although this also
does not require immediate attention. The polycythemia contributes to increased
bilirubin levels, usually beginning on the second day after delivery.
20. A nurse is reinforcing instructions to a new mother about cord care and how to
monitor for infection. The nurse tells the mother that which of the following is a sign
of infection?
1. A darkened drying stump
2. A moist cord with discharge
3. A purple stump that shows pinkness around the base
4. A purple stump that shows some moistness at the base
Answer: 2 Rationale: Signs of infection at the umbilical cord are moistness, oozing,
discharge, and a reddened base. If signs of infection occur, the health care provider
is notified. Antibiotic treatment may be necessary.
21. A nurse is caring for a 5-year-old child who has been placed in traction following
a fracture to the femur. Which of the following is the most appropriate activity for
this child?
1. Large picture books
2. A radio
3. A sports video
4. Finger paints
Answer: 4 Rationale: In the preschooler, play is simple and imaginative, and
includes activities such as dressing up, finger paints, clay, pasting, and simple board
and card games. Large picture books are most appropriate for the infant. A radio
and sports video are most appropriate for the adolescent.
22. The mother of a 16-year-old child tells the nurse that she is concerned because
the child sleeps until noon every weekend, and whenever the child has a day of
from school. The appropriate nursing response is which of the following?

1. The child should have a blood test to check for anemia.

2. Adolescents love to sleep late in the morning.
3. The child shouldnt be staying up so late at night.
4. If the child eats properly, that shouldnt be happening.
Answer: 2 Rationale: Sleep patterns in the adolescent vary according to individual
need. Adolescents love to sleep late in the morning but they should be encouraged
to be responsible for waking themselves, particularly in time to get ready for school.
Options 1, 3, and 4 are incorrect.
23. A 16-year-old child is admitted to the hospital for acute appendicitis and an
appendectomy is performed. Which of the following interventions is most
appropriate to facilitate normal growth and development?
1. Allow the family to bring in favorite computer games.
2. Encourage the parents to room in with the child.
3. Encourage the child to rest and read.
4. Allow the child to participate in activities with other individuals in the same age
group when the condition permits.
Answer: 4 Rationale: Adolescents often are not sure whether they want their parents
with them when they are hospitalized. Because of the importance of the peer group,
separation from friends is a source of anxiety. Ideally, the peer group will support
their ill friend. Options 1, 2, and 3 isolate the child from the peer group.
24. A 2-year-old child is treated in the emergency room for a burn to the chest and
abdomen. The child sustained the burn from grabbing a cup of hot cofee that was
left on the kitchen counter. The nurse reinforces safety principles with the parents
before discharge. Which statement, if made by the parents, indicates an
understanding of the measures to provide safety in the home?
1. I guess my children need to understand what the word 'hot means.
2. We will install a safety gate as soon as we get home so the children cant get
into the kitchen.
3. We will be sure that the children stay in their rooms when we work in the
kitchen.
4. We will be sure not to leave hot liquids unattended.
Answer: 4 Rationale: Toddlers, with their increased mobility and developing of motor
skills, can reach hot water, open fires, or hot objects placed on counters and stoves
above their eye level. Parents should be encouraged to remain in the kitchen when
preparing a meal and reminded to use the back burners on the stove; pot handles
should be turned inward and toward the middle of the stove. Hot liquids should
never be left unattended, and the toddler should always be supervised. Options 1,
2, and 3 do not reflect an adequate understanding of the principles of safety.
25. A nurse is reinforcing instructions with an adolescent with a history of seizures,
who is on an anticonvulsant medication. Which of the following statements, if made
by the adolescent, indicates an understanding of the instructions?

1. I will never be able to drive a car.

2. My anticonvulsant medication will clear up my skin.
3. I cant drink alcohol while I am taking my medication.
4. If I forget my morning medication, I can take just two pills at bedtime.
Answer: 3 Rationale: Alcohol will lower the seizure threshold and should be avoided.
Adolescents can obtain a drivers license, in most states, when they are seizure-free
for 1 year. Anticonvulsants cause acne and oily skin; therefore, a dermatologist may
need to be consulted. If an anticonvulsant medication is missed, the physician
should be notified.
26. A nurse is collecting data on a child admitted to the hospital with a diagnosis of
seizures. The nurse checks for causes of the seizure activity by:
1. Testing the childs urine for specific gravity
2. Obtaining a family history of psychiatric illness
3. Obtaining a history regarding factors that might precipitate seizure activity
4. Asking the child what happens during a seizure
Answer: 3 Rationale: Fever and infections increase the bodys metabolic rate. This
can cause seizure activity in children under the age of 5 years old. Dehydration and
electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can
cause head injury, which would increase intracranial pressure or cerebral edema.
Some medications could cause seizures. Specific gravity would not be a reliable test
because it varies, depending on the existing condition. Psychiatric illness has no
impact on seizure occurrence or cause. Children do not remember what happened
during the seizure itself.
27. A nurse is caring for a child recently diagnosed with cerebral palsy. The parents
of the child ask the nurse about the disorder. The nurse bases the response to the
parents on the understanding that cerebral palsy is:
1. A chronic disability characterized by a difficulty in controlling the muscles
2. An infectious disease of the central nervous system
3. An inflammation of the brain as a result of a viral illness
4. A congenital condition that results in moderate to severe retardation
Answer: 1 Rationale: Cerebral palsy is a chronic disability characterized by difficulty
in controlling the muscles as a result of an abnormality in the extrapyramidal or
pyramidal motor system. Meningitis is an infectious process of the central nervous
system. Encephalitis is an inflammation of the brain that occurs as a result of viral
illness or central nervous system infection. Down syndrome is an example of a
congenital condition that results in moderate to severe retardation.
28. A nurse is caring for a child with cerebral palsy. The primary goal to be included
in the plan of care is to:
1. Eliminate the cause of the disease.
2. Prevent the occurrence of emotional disturbances.

3. Maximize the childs assets and minimize the limitations

caused by the disease.
4. Improve muscle control and coordination.
Answer: 3 Rationale: The goal of managing the child with cerebral palsy is early
recognition and intervention to maximize the childs abilities. The cause of the
disease cannot be eliminated. It is best to minimize emotional disturbances. if
possible, but not to prevent them, because it is healthy for the child to express
emotions. Improvement of muscle control and coordination is a component of the
plan, but the primary goal is to maximize the childs assets and minimize the
limitations caused by the disease.
29. A nurse is assigned to care for an 8-year-old child
with a basilar skull fracture. Which of the following physician orders written in the
childs medical record would the nurse question?
1. Restrict fluid intake.
2. Keep an intravenous (IV) line patent.
3. Insert an indwelling urinary catheter.
4. Suction PRN.
Answer: 4 Rationale: Nasotracheal suctioning is contraindicated in a child with a
basilar skull fracture. Because of the nature of the injury, the suction catheter may
be introduced into the brain. The child may need a urinary catheter for accurate
monitoring of I&O. Fluids are restricted to prevent fluid overload. An IV line is
maintained to administer fluids or medications if necessary.
30. A lumbar puncture is performed on a child suspected of having bacterial
meningitis and cerebrospinal fluid (CSF) is obtained for analysis. The nurse
understands that which of the following results would verify the diagnosis?
1. Cloudy CSF with low protein and low glucose levels
2. Cloudy CSF with high protein and low glucose levels
3. Clear CSF with high protein and low glucose levels
4. Decreased pressure and cloudy CSF with high protein
level
Answer: 2 Rationale: A diagnosis of meningitis is made by testing CSF obtained by
lumbar puncture. In the case of bacterial meningitis, findings usually include
increased pressure, cloudy CSF, high protein level, and low glucose level.
31. Following tonsillectomy, the child begins to vomit bright
red blood. The initial nursing action would be to:
1. Administer the prescribed antiemetic.
2. Turn the child to the side.
3. Notify the registered nurse (RN.

4. Maintain an NPO status.

Answer: 2 Rationale: Following tonsillectomy, if bleeding occurs, the child is turned
to the side and the RN is notified, who will then contact the physician. An NPO
status would be maintained and an antiemetic may be prescribed; however, the
initial nursing action would be to turn the child to the side.
32. Following tonsillectomy, which of the following fluid or food items would be
appropriate to ofer to the child?
1. Cool cherry Kool-Aid
2. Vanilla pudding
3. Cold ginger ale
4. Jell-O
Answer: 4 Rationale: Following tonsillectomy, clear, cool liquids should be
administered. Citrus, carbonated, and extremely hot or cold liquids need to be
avoided because they may irritate the throat. Red liquids need to be avoided
because they give the appearance of blood if the child vomits. Milk and milk
products (pudding) are avoided because they coat the throat and cause the child to
clear the throat, thus increasing the risk of bleeding.
33. A nurse is reinforcing instructions to the mother of an 8-year-old child who had a
tonsillectomy. The mother tells the nurse that the child loves tacos and asks when
the child can safely eat one. The nurse makes which response to the mother?
1. In 1 week.
2. In 3 weeks.
3. Two days following surgery.
4. When the physician says its OK.
Answer: 2 Rationale: Rough, scratchy foods or spicy foods are to be avoided for 3
weeks. Citrus juices, which irritate the throat, need to be avoided for 10 days. Red
liquids are avoided because they will give the appearance of blood if the child
vomits. The mother is instructed to add full liquids on the second day and soft foods
as the child tolerates them.
34. A nurse reinforces instructions to the mother of a child with croup about the
measures to take if an acute spasmodic episode occurs. Which statement by the
mother indicates a need for further instruction?
1. I will place a steam vaporizer in my childs room.
2. I will place my child in a closed bathroom and allow my
child to inhale steam from the running water.
3. I will place a cool mist humidifier in my childs room.
4. I will take my child out into the cool, humid night air.
Answer: 1 Rationale: Steam from warm running water in a closed bathroom and cool
mist from a bedside humidifier are efective in reducing mucosal edema. Cool mist
humidifiersare recommended over steam vaporizers, which present a danger of

scald burns. Taking the child out into the cool humid night air may also relieve
mucosal swelling. Remember, however, that a cold mist may precipitate
bronchospasm.
35. A nurse is told that a child with rheumatic fever (RF) will be arriving to the
nursing unit for admission. On admission, the nurse prepares to ask the mother
which question to elicit information specific to the development of RF?
1. Did the child have a sore throat or an unexplained fever within the last 2
months?
2. Has the child had any nausea or vomiting?
3. Has the child complained of headaches?
4. Has the child complained of back pain?
Answer: 1 Rationale: RF characteristically presents 2 to 6 weeks following an
untreated or partially treated group A beta-hemolytic streptococcal infection of the
upper respiratory tract. Initially, the nurse determines if the child has had a sore
throat or an unexplained fever within the past 2 months. Options 2, 3, and 4 are
unrelated RF.
36. Acetylsalicylic acid (Aspirin) is prescribed for the child with rheumatic fever. The
nurse would question this order if the child had documented evidence of which of
the following?
1. A viral infection
2. Joint pain
3. Facial edema
4. Arthralgia
Answer: 1 Rationale: Anti-inflammatory agents, including aspirin, may be prescribed
for the child with RF. Aspirin should not begiven to a child who has chickenpox or
other viral infections such as the flu. Options 2 and 4 are clinical manifestationsof
RF. Facial edema may be associated with the development of a cardiac
complication.
37. A nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF).
The nurse reviews the laboratory results, knowing that which laboratory study would
assist in confirming the diagnosis of RF?
1. White blood cell count
2. Red blood cell count
3. Immunoglobulin
4. Antistreptolysin O titer
Answer: 4 Rationale: A diagnosis of RF is confirmed by the presence of two major
manifestations or one major and two minor manifestations from the Jones criteria.
Additionally, evidence of a recent streptococcal infection is confirmed by a positive
antistreptolysin O titer, streptozyme, or an anti-DNase B assay. Options 1, 2, and 3
will not assist in confirming the diagnosis of RF.

38. A nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of
the child asks the nurse about the disorder. The nurse tells the mother that:
1. It is an acquired cell-mediated immunodeficiency disorder.
2. It is an inflammatory autoimmune disease that afects the connective tissue of
the heart, joints, and subcutaneous tissues.
3. It is a chronic multisystem autoimmune disease characterized by the
inflammation of connective tissue.
4. Is also called mucocutaneous lymph node syndrome and a febrile generalized
vasculitis of unknown cause.
Answer: 4 Rationale: Kawasaki disease, also called mucocutaneous lymph node
syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes
human immunodeficiency virus (HIV) infection. Option 2 describes rheumatic fever.
Option 3 describes systemic lupus erythematosus.
39. A nurse collects a urine specimen preoperatively from a child with epispadias
who is scheduled for surgical repair. The nurse reviews the childs record for the
laboratory results of the urine test and would most likely expect to note which of the
following?
1. Hematuria
2. Proteinuria
3. Bacteriuria
4. Glucosuria
Answer: 3 Rationale: Epispadias is a congenital defect involving abnormal
placement of the urethral orifice of the penis. The urethral opening is located
anywhere on the dorsum of the penis. This anatomical characteristic leads to the
easy access of bacterial entry into the urine. Options 1, 2, and4 are not
characteristically noted in this condition.
40. A 1-year-old child with hypospadias is scheduled for surgery to correct this
condition. A nurse is asked to assist in preparing a plan of care for this child and
makes suggestions, knowing that this surgery is taking place at a time when:
1. Fears of separation and mutilation are great.
2. Sibling rivalry will cause regression to occur.
3. Embarrassment of voiding irregularities is common.
4. Concern over size and function of the penis is present.
Answer: 1 Rationale: At the age of 1 year, a childs fears of separation and
mutilation are great, because the child is facing the developmental task of trusting
others. As the child gets older, fears about virility and reproductive ability may
surface. The question does not provide enough data to determine that siblings
exist. Options 3 and 4 may be issues if the child were older.
41. An 18-month-old child is being discharged following surgical repair of
hypospadias. Which postoperative nursing care measure should the nurse stress to
the parents as they prepare to take this child home?

1. Encourage toilet training to ensure that flow of urine is normal

2. Restrict fluid intake to reduce urinary output for the first few days
3. Avoid tub baths until the stent has been removed
4. Leave the diapers of to allow the site to heal
Answer: 3 Rationale: Following hypospadias repair, the parents are instructed to
avoid giving the child a tub bath until the stent has been removed to prevent
infection. Diapers are placed on the child to prevent contamination of the surgical
site. Fluids should be encouraged to maintain hydration. Toilet training should not
be an issue during this stressful period.
42. A nurse is reviewing the treatment plan with the parents of a newborn infant
with hypospadias. Which statement by the parents indicates their understanding of
the plan?
1. Circumcision has been delayed to save tissue for surgical repair.
2. Catheterization will be necessary if my infant does not void.
3. Caution should be used when straddling my infant on a hip.
4. Vital signs should be taken daily to check for bladder infection.
Answer: 1 Rationale: Hypospadias is a congenital defect involving abnormal
placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is
located below the glans penis along the ventral surface. The infant should not be
circumcised because the dorsal foreskin tissue will be used for surgical repair of the
hypospadias. Options 2, 3, and 4 are unrelated to this disorder.
43. Corticream is prescribed by the physician for a child with atopic dermatitis
(eczema) and the nurse instructs the mother how to apply the cream. The nurse
tells the mother to:
1. Avoid cleansing the area before applying the cream
2. Apply the cream over the entire body
3. Apply a thin layer of cream and rub into the area thoroughly
4. Apply a thick layer of cream in afected areas only
Answer: 3 Rationale: Corticream is a topical corticosteroid. It should be applied
sparingly and rubbed into the area thoroughly. The afected area should be cleansed
gently before application. It should not be applied over extensive areas. Systemic
absorption is more likely to occur with extensive application.
44. A nurse assists in providing an instructional session to parents regarding
impetigo. Which statement by a parent indicates a need for further instruction?
1. It is most common in humid weather.
2. It begins in an area of broken skin, such as an insec bite.
3. It is extremely contagious.
4. Lesions are most often located on the arms and chest.

Answer: 4 Rationale: Impetigo is most common during hot, humid summer months.
It begins in an area of broken skin, such as an insect bite. It may be caused by
Staphylococcus aureus, group A beta-hemolytic streptococci, or a combination of
these bacteria. It is extremely contagious. Lesions are usually located around the
mouth and nose, but may be present on the extremities.
45. A client is preparing for discharge after undergoing a radical vulvectomy. The
nurse plans to tell the client that which activity is acceptable after discharge
because it will not precipitate complications?
1. Sexual activity
2. Walking
3. Sitting for lengthy periods
4. Driving a car
Answer: 2 Rationale: The client should resume activity slowly, and walking is a
beneficial activity. The client should be instructed to rest when fatigue occurs.
Activities to be avoided include driving, heavy housework, wearing tight clothing,
crossing the legs, and prolonged standing or sitting. Sexual activity is prohibited for
4 to 6 weeks after surgery.